Population Health Coordinator in Greenfield, Massachusetts at Community Health Center of Franklin County Inc

PRIMARY RESPONSIBILITIES:

• Utilize the EPIC electronic medical record to perform pre-visit planning, identify care gaps, and support provider workflows
• Conduct outreach to patients who are due or overdue for preventive care, chronic disease management, and quality related services
• Support providers and care teams by preparing patient information and identifying outstanding clinical needs prior to visit
• Coordinate and schedule patient care to ensure timely completion of recommended screenings, follow-ups and interventions
• Accurately document all outreach, patient interactions, and care coordination activities within EPIC
• Monitor and track quality measure performance and patient outreach efforts using EPIC and internal reporting tools
• Collaborate with clinical teams to improve workflows, patient access, and care delivery process
• Participate in quality improvement initiatives aligned with UDS, ACO, and other value-based care programs
• Communicate effectively with patients regarding recommended care and support engagement in their health
• Attend and participate in relevant meetings, trainings, and workgroups related to population health and quality improvement
• Ensure compliance with organizational policies, regulatory requirements, and quality standards

REQUIRED SKILLS, EDUCATION & EXPERIENCE:

• High school diploma required; Associate's degree in healthcare, public health or related field preferred
• Experience in healthcare or medical office setting required; population health, care coordination, or quality experience preferred
• Experience with EPIC electronic medical record strongly preferred
• Strong organizational skills with the ability to manage multiple priorities and meet deadlines
• Ability to work independently while collaborating within a multidisciplinary team environment
• Proficiency in Microsoft Office (Excel, Word, Outlook)
• Attention to detail with strong documentation and data tracking skills
• Ability to work with diverse patient populations and demonstrate cultural sensitivity
• Commitment to CHCFC's mission, vision, and values

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to stand, walk, sit, use the hands to finger, handle or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. Must be able to lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

WORKING CONDITIONS:

While performing the required duties of this job, the employee is exposed to weather conditions prevalent when traveling between Health Center locations where medical care is provided. This position performs tasks that involve exposure to blood, body fluids or tissues.

This job description is subject to review in the light of changing circumstances and is not intended to be rigid and inflexible but should be regarded as providing guidelines within which the employee works. Performs other duties as assigned.